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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 26, No 4, July/August 2015
AFRICA
e15
Unusual complication of aortic dissections:
intimo–intimal intussusception
Unsal Vural, Ahmet Yavuz Balci, Ahmet Arif Aglar, Mehmet Kizilay,
İ
brahim Yekeler, Abdullah Kemal Tuygun
Abstract
Angiography with a pre-diagnosis of acute coronary syndrome
was performed in a 76-year-old female patient presenting to
another hospital with symptoms of chest pain and syncope.
Upon determination of type III aortic dissection, the patient
was referred to our clinic. On CT angiography, the ascend-
ing aortic diameter was 57 mm and no dissection flap was
observed. There was a filling defect suggestive of intimo–inti-
mal intussusception at the level of the aortic arch, occlusion
of the left arteria carotid communis, and a double-channel
aorta extending from the left subclavian artery to the iliac
artery. On transoesophageal echocardiography, the ascending
aorta was seen to be larger than normal and no dissection
flap was observed. There were findings suggestive of haema-
toma and intimo–intimal intussusception at the proximal
part of the aortic arch. The dissection flap causing occlu-
sion in the vascular structures was resected. Supracoronary
graft replacement of the ascending aorta was performed.
Transoesophageal echocardiography is an invasive investiga-
tive method with high sensitivity and specificity for the diag-
nosis of intimo–intimal intussusception.
Keywords:
intimo-intimal intussusception, complication of
aortic dissections, DeBakey type I and type II, surgical treat-
ment, urgent surgical intervention
Submitted 30/12/14, accepted 16/3/15
Cardiovasc J Afr
2015;
26
: e15–e18
www.cvja.co.zaDOI: 10.5830/CVJA-2015-029
Intimo–intimal intussusception is a rare but fatal complication
of aortic dissection. Emergency surgery is a life-saving procedure
in aortic dissection. Intimo–intimal intussusception is an atypical
manifestation of aortic dissection produced by circumferential
dissection of the media and intimal layer of the aorta and
invagination of the intimal flap in the aortic arch in DeBakey
type I and type II aortic dissections.
Due to the absence of the intimal flap and crescent
sign in the ascending aorta, it is difficult to diagnose this
condition. A definitive diagnosis is made on transoesophageal
echocardiography (TEE) with the observation of a prolapse
of the dissection flap into the ascending aorta. Delaying the
diagnosis may result in delayed treatment and increased risk
of mortality. We present our case with a literature review of
diagnosis and treatment of intimo-intimal intussusception.
Case report
Angiography was performed for a pre-diagnosis of acute
coronary syndrome in this case presenting to a cardiology centre
with symptoms of syncope and chest pain lasting for three days.
She was referred to our clinic with a pre-diagnosis of type III
aortic dissection since a catheter had been placed into the false
lumen and it could not be advanced into the aortic arch.
The 76-year-old female patient was admitted for the purpose
of investigation and treatment. It was learned from her history
that she had had hypertension for 10 years, and had been
receiving treatment for 15 years for diabetes mellitus. On physical
examination, she had poor consciousness with a poor general
condition and a tendency to sleepiness. Her blood pressure and
pulse rate were determined at 180/100 mmHg and 120 beats/min,
respectively. Her left radial pulse was absent.
While the rhythm on a 12-lead ECG tracing taken three
days earlier was normal sinus rhythm, the rhythm was ‘atrial
fibrillation’ on the subsequent ECG. There was no finding
suggestive of coronary ischaemia. Troponin T levels were within
the normal ranges (troponin T = 0.05 ng/ml). Echocardiography
was reported as ‘left ventricular functions were normal, the
ascending aorta and the aortic root were larger than the normal
diameter of the aorta, a mild aortic valve regurgitation was
present, pericardial effusion was absent, no dissection flap was
determined in the ascending aorta’.
On CT angiography, the ascending aortic diameter was
57 mm and no dissection flap was present. A filling defect
suggestive of intimo–intimal intussusception was observed at
the level of the aortic arch. The left arteria carotid communis
was occluded from the left subclavian artery. A double-channel
aorta extending to the iliac artery was observed in the thoracic
and abdominal aorta (Fig. 1).
On TEE, the ascending aorta was seen to be larger than
normal and no dissection flap was observed. There was the
Dr Siyami Ersek Thoracic and Cardiovascular Surgery
Center, Istanbul, Turkey
Unsal Vural, MD,
unsalvural@gmail.comAhmet Yavuz Balci, MD
Ahmet Arif Aglar, MD
Mehmet Kizilay, MD
İ
brahim Yekeler, PhD, MD
Abdullah Kemal Tuygun, MD, PhD
Case Report